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Press Briefing Transcripts

Weekly 2009 H1N1 Flu Media Briefing

October 29, 2009, 2p.m.

Audio recording (MPEG)

Operator: Welcome and thank you all for standing by. At this time I'd like to remind parties that your lines are in a listen only mode until the question and answer session at which time you may press star to ask a question. Today's call is being recorded if you have any objections, disconnect at this time. I will now turn the meeting over to Dave Daigle. Thank you, sir, you may begin.

Dave Daigle: Hi, I'm Dave Daigle from CDC Media Relations. Today the Dr. Anne Schuchat, the director of the National Center for Immunization and Respiratory Diseases will give us an update on the H1N1 virus.

Anne Schuchat: Good afternoon, everyone. We’ve been carrying out twice weekly full press briefings and today we’re just going to give you a little bit of an update. We know that a lot of people have been asking about a few issues. A lot of people are asking about a few issues about vaccines and antivirals. So I'll just briefly catch folks off that. The vaccine distribution and a little bit about anti-viral use. We're expecting a more full briefing tomorrow with new epidemiologic data as well. I want to let you know that as of today, there are 24.8 million doses of the H1N1 vaccine that are available for the states to order. That's 1.6 million more than yesterday. And as we've been saying, although we aren't where we want to be with vaccine availability, we are seeing forward progress with more and more doses becoming available regularly. I know that it's hard to find in many places. And a lot of people do want to be vaccinated which is great. I appreciate the frustration people are seeing as they are unable to find vaccine. And over the next several weeks it should become more easily available. And as I've been saying each day we are seeing forward progress. We're expecting a lot of vaccination effort this is weekend in a number of places. I want to express my appreciation for the incredible work that the state and local health departments are doing in what is a challenging circumstance. We all had hoped to have more vaccine by now than we have. And so states and locals have had to adapt their plans about how many doses will be coming in the days ahead and where to have them delivered, about how to run those clinics. But as you’ve been seeing around the country, more and more states have been finding that they have sufficient doses to initiate school located clinics and some other mass clinics. As well, many doctor's offices are beginning to get doses. So hopefully things will be getting better. As I said, we're not where we had hoped to have been at this point.

I want to mention a few things about antivirals. There have been some reports about people having trouble finding antivirals, particularly for children. So, what have we been doing about this? A few weeks ago the secretary ordered 300,000 courses of the liquid Tamiflu for children to be shipped out to the states. And that's all going out to the state through the strategic national stockpile. We know there are also capsules of the anti-viral medicine. There are many different size capsules. Many of those are fine for children. In addition, we're working closely with the manufacturers to really understand the supply horizon and understand what is out there in the commercial sector. We're working closely with the states who are managing their stockpiles of these antivirals to get them to the places that don't have them. What we think is going on is really much more of a spot shortage that here and there, you know, there's a pharmacy that doesn't have usually the liquid formulation. But there is quite bit of the capsule formulations out there. There are ways that pharmacies and pharmacists can use the capsules to adapt dosing that is appropriate for children. And we've worked with the FDA and the pharmacists and pharmacies to get information about how to use those capsules, something called compounding where you basically break up the capsules and mix it with a liquid syrup and can have an appropriate dose for kids. So we know that a number of chain pharmacies are doing compounding now. And this should be much more accessible to parents.

There's also information for parents. If your doctor prescribed capsules for your kids but your kids are just not going to take a capsule, there's a way for you to at home break up the capsule, mix it with a liquid syrup like chocolate syrup or unsweetened chocolate syrup and have something that your child can tolerate. I want to remind people about antivirals. They are very important part of our response to the H1N1 virus. Fortunately, most people who get infected with the H1N1 will do fine just with a few days of bed rest and care and, you know, not going to work or school and infecting other people. But don't even need to seek care. But some people do need to seek care and do really need to receive the antiviral medicines. And there are really great tips for parents on flu.gov about warning signs to look for in your child, whether it's important to seek care or not, or whether things are looking okay but start to look worse and you really need to get back in touch with your provider. So when antivirals are prescribed, we want to let people know that there is more out there in the supply system. The formulation that you thought you were going to get may not be the one you were expecting. But that kids can take the capsules mixed in with the syrup and that should be just fine. We're working very closely with the states to understand their needs and be able to fill the gaps that are there. So with that I want to move to questions that people may have. We can start with something in the room if there's a question here.

Betsy McKay: Betsy McKay with Wall Street Journal, a couple questions. I wondered if you'd be able to tell us how many doses have been shipped and also how many -- do you have how many doses have actually been administered? And the second thing is do you have an update on pediatric deaths?

Anne Schuchat: Tomorrow we'll be updating on the pediatric deaths. We do know that a number -- the number of children who have died has increased since our last report. But the full summary will be available tomorrow. And we expect there to be more, unfortunately. The issue with the doses shipped, last spring we sent out about 11 million courses of antivirals including a number of courses for children. October 1st there was an order for an additional 300,000 bottles of the liquid Tamiflu to go out to states to supplement what was already there. The commercial sector is increasing production of the Tamiflu and, of course, there is also Ralenza available. Important to say that capsule production is what is -- has really been increased. There are more and more capsules being made or shipped out. And what we want parents to know is that capsules are fine for kids, even kids that can't swallow pills because there's a way for either the pharmacist or for you at home to convert that capsule into a liquid. The -- I think those were your questions. Did I miss one? I'm sorry. Okay. Right. So that number I don't have. It will come tomorrow. What we're trying to do, just to say we realize that people want information. We want to get you more information, more readily than we have. And I believe pretty soon we'll start to really just post something every day so you can keep track of it. But the shipping information comes in a little bit later than the doses allocated. So hopefully fairly soon you'll be able to follow the progress without us having to call you all in for a press briefing. Okay, another one from the room?

Beth Galvin: Thank you. I'm with Fox 5. I'm just wondering, talking to the flu vaccine manufacturers, what are you hearing from them? What about the delay? Is that going to be something that's going to be ongoing into the future?

Anne Schuchat: There's very active communication with the manufacturers. Of course, we have been talking about this delay in production. And a couple of the factors that led to that are the slow growing virus, the virus just not cooperating in the eggs. And really working closely with the manufacturers to understand what's coming out of manufacturing and what we can expect week to week. Very important to get accurate information so that we can pass that along to the states who are really planning how to use very quickly the doses that get to them. So I know that there's active dialogue. I don't have an update on projections. We had announced that, you know, we were not expected to make the targets by the end of this month. Of course, we won't be making them. But as I said, we are at, as of today, 24.8 million that is allocated to the states for order. So going forward, I think, you know, there is some of the challenges that they have which we believe they've been able to improve. You know, changing the strength so the virus is growing better and some of those fill-finish lines that need to be cleared are now cleared. But we're really trying to avoid estimating exactly how much we're going to have from week to week other than working closely with the states so that they can use the doses as they come out to them. Question from the phone?

Operator: Elizabeth Weise, USA Today your line is open.

Elizabeth Weise: Thank you for taking my call. I wanted to find out, you were talking about the pediatric death rates. Do we have overall death and hospitalization rates for the first wave in the spring and then now the full ever since the flu began?

Anne Schuchat: Right. I can call people's attention to a paper that just came out online in Emerging Infectious Diseases. Carrie Reed is the first author of that paper. She and her colleagues here at CDC estimated the burden of disease in the spring really going from April when this virus first emerged to I think it's July 23rd, really using a modeling approach to take cases that were reported or hospitalization that's were reported and estimating how much really happened? We have been saying that we were just finding the tip of the iceberg with our laboratory confirmed reporting. And, of course, in July we switched away from an individual case counting to other methods. In that paper, although there have been about 44,000 lab confirmed cases reported during that time period, the estimate was between 1.8 and 5.7 million total cases. So a lot more cases than were actually reported through that lab individual case system. Now when you have common conditions like this, it's just not that efficient to use resources to individually count every one of them. And what we do is move to modeling approaches.

They also estimated that there were between 9,000 and 21,000 hospitalization cases during that same time period. Again, more than what we got reports of from the lab confirmed system. And just to think it through, not every case that occurs will result in a person seeking medical care, not every person who seeks medical care will be tested for flu. Not every person who is tested for flu will have a result that is positive. Not every positive result will get reported. And so forth. And so you can imagine how what we count, whether it's cases or hospitalizations or deaths will be underestimates of the full burden. And more and more epidemiologists are looking towards modeling. We don't have an update since the July 24th with this modeling approach. But as Dr. Frieden said last week, we believe many millions of people have already contracted this virus here in the U.S. and that we have had, you know, probably by now well more than 20,000 hospitalizations. This model suggests that even by July we had 20,000 hospitalizations possibly. So, you know, the important thing to say is we're working actively on understanding what's going on and looking forward. And really the priority is to minimize the continuing serious illness and death that we're seeing through these interventions like prompt use of antiviral medicines and vaccination as soon as it becomes available. Another question from the phones?

Operator: Mike Stobbe from Associated Press, your line is open.

Mike Stobbe: Hi. Doctor, thank you for taking the call. Hey, the Tamiflu shortage for children that was first reported a month ago. Can you tell me has it been getting worse or better or have the shortages been moving to different parts of the country? What's been going on in that last month?

Anne Schuchat: You know, we've seen an increased use of the Tamiflu or oseltamivir from the surveillance tracking systems. We're seeing increased use. We believe a higher use among those with underlying conditions who are, you know, when they get flulike illness we recommend they be treated. We are not aware that things are worse. When he done supply projections last month that led to that shipment. October 1st we shipped out the liquid Tamiflu based on projections. We were looking forward at how much is out there and how much is in the system and if things continue with children and children getting ill, will we have enough of the different formulations? So we tried to ship that out before there was a problem. We're not aware of a widespread problem. We are aware from media reports of anecdotal concerns where people are having to call around a lot to find a pharmacy that has the medicines. And so we take that kind of concern seriously and want to let people know that the capsules should be an ample supply and the adult capsules in very ample supply and there are ways pharmacies or you can convert the adult capsules into medicines for kids. And then, of course, the pediatric capsules can be mixed up at home with the syrup. So we're not aware that it's getting worse. We're just aware that, you know, we're seeing a lot of people with flu illness seeking -- who are being prescribed medicine. We want to help with the spot shortage that's have been reported. So another call -- question from the phones?

Operator: The next is from Daniel DeNoon, WebMD.

Daniel DeNoon: Doctor, going back to the EID paper. There is a multiplier that has been used to estimate the cases of 79 cases for each report that you received. Do those -- and a similar is for three per hospitalizations. Do the multipliers still apply? Could we use those kinds of modeling to guess how many people, how many cases there have been and how many hospitalizations there have been as of now?

Anne Schuchat: I think that paper is very helpful in providing a method, a methodology. I think the multipliers need to be taken for a grain of salt. If we think back to April and May, early cases, of course, there was a keen interest in finding out whether this virus had arrived in a place. And a lot more people with milder symptoms were being tested. We don't actually get reports anymore of the individual cases. We only get summary reports of hospitalizations. So the case multiplier would be a challenging thing to track. The hospitalization multiplier might also need to be taken with a grain of salt at this time because we do also have a possibility that some people were being hospitalized early in this outbreak for different reasons than they would be now when this was a new -- newly recognized virus. There were probably some precautionary hospitalizations. So I think that it's an instructive and very helpful analysis. But taking it sort of exactly as is with those multipliers might lead to problems. Next question from the phone?

Operator: The next is from Robert Bazell, NBC news.

Robert Bazell: Hi, doctor. Thank you for taking my call. Two questions if I may. The first is speaking to practitioners, especially pediatricians and internists who are not infectious diseases specialists, they say they're mighty confused by the CDC’s recommendations about when to use antivirals. I know you've changed them over time and that the perception of whether there's going to be a shortage and the perception of whether there is a risk of creating resistance has changed over time. And I don't know that you could clear this up in a second. But do you understand why that's the case? And I do have a second question if you'll stay with me.

Anne Schuchat: Sure. Clinical judgment is always important. And I really value the hard work that private -- the frontline practitioners are doing to care for people and to determine whether their patients should come in to see them or just talking with them over the phone. What we recommend right now for antiviral medicines is that focus be on treatment, not on preventative use of the medicines. And that the focus be on treatment of people who have severe presentations, anyone who is hospitalized with suspect or likely flu, whatever kind of flu, should be treated. And you shouldn't wait for the results of a test because that test results even a negative may not be right and it may take some time. So prompt treatment of people with severe illness like those who are hospitalized is important. People with respiratory symptoms and fever, influenza like illness who have chronic conditions like asthma, who are pregnant, who have diabetes, who are very young like children under 2, those are groups where we do recommend antiviral use be the general approach. And then for people who are older -- healthy, otherwise healthy without the chronic conditions who are not pregnant. If they have severe presentations or warning signs, they may not be hospitalized, but they may be actually showing some warning signs in terms of difficulty breathing and so forth that medicines could be important in those circumstances. But for the vast majority of people who have an illness that isn't severe and who don't have the underlying factors like very young age, pregnancy or chronic health conditions, probably just bed rest, fluids and a little TLC is the right way to go. You know, in all of our guidance we really stress that that provider-patient relationship is very important. We think doctors probably do know their patients well and can sense whether things just aren't right. For parents, at flu.gov, there is really helpful information about warning signs to watch for in your children. I encourage you to take a look at. You don’t have to just look once. If your child is ill and things are changing a little bit, go look that up again and see how they're doing or give your doctor another call if you're worried. We know that parents have pretty good intuition of something not being right with their children. You have a follow-up?

Robert Bazell: Yes, can still understand why parents and providers is going to be wanting to have antivirals because of just fear and this is the drug that's out there, it's available and it can be used. And you say the patient-doctor relationship is important. Of course this is something that is fairly new to a lot of people. They haven't seen so much illness in young adults. This is one thing. The second thing is that I want you -- would like you to answer is that -- we talked to pharmacists who say they will not formulate Tamiflu because they don't know how to do it. Yet, you're saying that parents should do this at home. Isn't there a danger of parents mixing up drugs at home with chocolate syrup or something else that could end up giving the child the wrong dose?

Anne Schuchat: Thanks for those two questions. I definitely understand that the challenges of our anti-viral -- of our antiviral messages. This is not a black and white situation. Unfortunately, a lot of clinical medicine is like that that evaluation, careful evaluation, talking to the parent really understanding what's going on is very important. What we've tried to do at CDC and with health care community in general is to put out put algorithms that can be helpful, warning signs to watch for, general guidance that can be benchmark for people knowing that that clinical judgment is just as important. Unfortunately we don’t have a perfect black and white test that will tell you that this personal absolutely needs medicine, this person definitely doesn’t. But we can say that the vast majority of people get better without medicines. And that some people need medicines very promptly. So it's tricky message. It’s one I hope it's one we can work together in getting out more clearly.

Your second question is about the pharmacists and parents. It's just apples and oranges. We are asking pharmacists to do something called compounding. They're taking capsules and looking at body weights and dosing and sort of mixing up a couple capsules, maybe more than one capsule with a certain amount of liquid and doing something really under pharmacist’s attention that is with a prescription sort of guidance. We know that some pharmacists don't want to do that, but a lot more and more are saying that they will be part of the solution. A number of the chains, I think I mentioned Walmart and Walgreens, I think I’ve heard recently that Rite-Aid and CVS and many states are saying the pharmacist will do this compounding. Very, very different what we're telling parents. Parents should not compound. At flu.gov, there is information for patients. If you come home if the pharmacy with a prescription from your doctor that is pills and says one pill a day or whatever and you can't get your child to take that pill, there is -- there is a way for you to break up open that pill, mix it with a little syrup and have your child take the full spoonful of the syrup. Very, very different than what we're asking the pharmacist to do. We don't want parents to have to become pharmacists. You have a full-time job being a parent. Next question from the phones?

Operator: Dr. Jon LaPook, medical correspondent, your line is open.

Jon LaPook: Hi. Public health officials believe that ICU’s release of antivirals and soon vaccination will make a big difference in the survival of people with H1N1. In parts of the world that don't have these resources right now, is there evidence of increased mortality compared to that seen in the United States?

Anne Schuchat: I’m not aware of information about that yet. But that's a really good question. We work closely with the World Health Organization and partners around the world to understand what's going on and try to help with the situation. We do think that each country has their own challenges and so I don't actually have data to speak to that. I can say, though, that the way that we track illness is a bit different in different countries. You know, some are focusing on illness that's in the hospital. Some are focusing on community surveys of what's going on. So even just comparing what the mortality is country to country is relatively complex. And I think we have time for one more question from the phone.

Operator: The next is from Brian Hartman, ABC. Your line is open.

Brian Hartman: I wonder how tightly do you control the throttle and production of the vaccine? I know that, you know, once the initial you are rush of doctors who really want this vaccine get their shots and get the nasal spray. How do you then calibrate the supply so you don't just end up with a warehouse full of doses that nobody's ever going to get?

Anne Schuchat: We are working very closely with the manufacturers and the states and the private sector to make vaccine available as quickly as it's produced. You know, it's going from manufacturers to a central distributor and then out to the states. And they have a population based formula for how much they get. They are using it as quickly as they can, you know, ordering it as it becomes available and sending it out to many places. I think over the weeks ahead we'll get an idea of where things are with better and better supply and possibly changing demand. One thing I do want to say, though, is over the weeks and months ahead, we may see fluctuations in disease. Disease may go up further. It may start to come down. Even if disease comes down, I think we need to be mindful of the lessons of the past. In 1957 disease went up and then came down towards the end of the fall. And people thought, you know, we don't need to bother to vaccinate. It turned out there was a big, big wave after the first of the year in February and March. And so I think that we'll need to be keeping our eye on demand, as well as the increase in supply and really understand the best way to prevent disease as much as we can. So thanks everybody for this and there will be something more detailed tomorrow.

Dave Daigle: I think we are shooting for 1:30 tomorrow with Dr. Frieden. Thanks. Thank you.